Instruments and methods for stabilization of bony structures

ABSTRACT

The present invention relates to methods and instruments for placing a brace or connecting element into an animal subject for engagement with anchors secured in the animal subject. The installation instrument includes anchor extensions coupled to the anchors. The instrument is movable with respect to the anchors to position the conencting element in a position more proximate the anchors.

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] The present application is a continuation-in-part of U.S. patent application Ser. No. 09/616,581 filed on Jul. 14, 2000, which claims the benefit of the filing dates of Provisional Application Serial No. 60/186,729, filed Mar. 3, 2000 and Provisional Application Serial No. 60/160,489, filed Oct. 20, 1999. The referenced applications are each incorporated herein by reference in their entirety.

BACKGROUND OF THE INVENTION

[0002] The present invention generally relates to surgical instruments and methods for use of the same, and more particularly, but not exclusively, relates to instruments and methods for stabilizing bony structures.

[0003] The use of various devices and methods for stabilizing bone structures have been used for many years. For example, the fracture of an elongated bone, such as a femur or humerus, can be stabilized by securing a plate to the fractured bone across the fracture. The plate extends across the fractured area and thus stabilizes the fractured components of the bones relative to one another in a desired position. When the fracture heals, the plate can be removed or left in place, depending on the type of plate that is used.

[0004] Another type of stabilization technique uses one or more elongated rods extending between components of a bony structure and secured to the bony structure to stabilize the components relative to one another. The components of the bony structure are exposed and one or more bone engaging fasteners are placed into each component. The elongated rod is then secured to the bone engaging fasteners in order to stabilize the components of the bony structure.

[0005] One problem associated with the above described stabilization structures is that the skin and tissue surrounding the surgical site must be cut, removed, and/or repositioned in order for the surgeon to access the location where the stabilization device is to be installed. This repositioning of tissue causes trauma, damage, and scarring to the tissue. There are also risks that the tissue will become infected and that a long recovery time will be required after surgery for the tissue to heal.

[0006] Minimally invasive surgical techniques are particularly desirable in, for example, spinal and neurosurgical applications because of the need for access to locations deep within the body and the danger of damage to vital intervening tissues. The development of percutaneous minimally invasive spinal procedures has yielded a major improvement in reducing recovery time and post-operative pain because they require minimal, if any, muscle dissection and can be performed under local anesthesia. These benefits of minimally invasive techniques have also found application in surgeries for other locations in the body where it is desirable to minimize tissue disruption.

[0007] Examples of instruments and techniques for performing surgeries using minimally invasive techniques are found in U.S. Pat. Nos. 5,792,044 and 5,902,231 to Foley et al. While these techniques are steps in the right direction, there remains a need for instruments and methods for stabilizing bony structures using minimally invasive techniques. This need and others are addressed by the present invention.

SUMMARY OF THE INVENTION

[0008] The present invention relates to devices and methods for insertion of an orthopedic brace or connecting element to one or more anchors secured to an animal subject.

[0009] In one aspect of the invention, there is provided a method for using an instrument to connect at least two bone anchors with a connecting element. The instrument is secured to one or both the anchors and manipulated to place the connecting element in a position more proximate at least one of the anchors.

[0010] In another aspect of the present invention, there is provided a method that includes: placing at least two anchors in a bony structure, each of the anchors having an extension associated therewith; attaching a brace inserter of an installation instrument to the extensions; and guiding a brace into a desired position relative to the anchors.

[0011] In a further aspect of the invention, there is provided an instrument for placing a brace or connecting element into a desired position relative to at least two anchors. The instrument employs a fixed geometric relationship to guide the connecting element into a position proximate the anchors.

[0012] In yet a further aspect of the invention, there is provided an instrument for placing a connecting element into a desired position proximate the location of two anchors. The instrument is mounted to the at least two anchors and holds the connecting element in spatial relation to the anchors about a pivot point. The instrument is rotated about the pivot point to guide the connecting element to the desired position.

[0013] According to an additional aspect of the invention, there is provided an installation instrument having a brace secured thereto. The brace is indexed so that the brace can assume only a desired orientation when secured to the installation instrument.

[0014] According to one aspect of the invention, the percutaneous brace placement device includes first and second anchor extensions and a pivoting brace inserter mounted to the anchor extensions about a pivot axis. The pivoting brace inserter includes an arm having a brace mounting portion at its distal end for connecting an orthopedic brace to the device.

[0015] In another aspect of the present invention, the installation instrument includes a support arm engaged to the anchor extension. An anchor is engaged to the distal end of each anchor extension. Preferably, the anchors are in the form of a multi-axial screw capable of allowing universal rotation of the anchor extension. In one form, the arm is located at a predetermined radius from the pivot axis and in a curve at a substantially constant radius relative to the pivot axis to the brace mounting portion. In yet another form, a brace gripper or coupler is operable to selectively grip and release an orthopedic brace from the inserter. In another form, a brace has one end connected at the brace mounting portion and an opposite end adapted to puncture soft tissue of an animal body. Preferably, the brace and pivot arm lie in a circle centered on the pivot axis at a constant radius. The brace is curved at the constant radius relative to the pivot axis in one plane, and the brace is oriented to lie in the circle.

[0016] According to another aspect of the invention, a method of installing an orthopedic brace in an animal subject is provided. The method comprises placing first and second anchors mounted on first and second anchor extensions, respectively, percutaneously in first and second bony parts of the body of the subject; mounting a brace inserter on the anchor extensions, the inserter having a pivot axis about the anchor extensions; mounting the brace on the pivoting brace inserter; and swinging the brace inserter relative to the anchor extensions about the pivot axis and thereby moving the brace in a forward direction through an arc centered on the pivot axis and introducing an end of the brace percutaneously to the location of the anchors. In a further form, the brace is fixed to the anchors; the inserter disconnected from the brace; and the inserter moved in a reverse direction through the arc and to remove the inserter from the body. Preferably, the brace is a shaft curved at a single radius about an axis co-linear with the pivot axis of the arc, and the method further includes introducing the shaft through receivers in the anchors during the introduction step.

[0017] In yet another aspect of the present invention, anchors, or anchors and anchor extensions are placed by image guided navigation to locate optimum placement and orientation of the anchors in pedicles of vertebral bodies of a single level of the spine of the animal. The image guided technology is also used to determine animal skin locations for percutaneous puncture entry of the anchors. In one form the anchors are cannulated and inserted over guidewires anchored in the vertebral bodies.

[0018] According to another aspect of the invention, a technique for spinal fusion of adjacent vertebral bodies of the animal spine is provided. The method includes removal of intervertebral disc material from the space between first and second vertebral bodies of the subject. One or more interbody fusion devices are introduced into the space. First and second anchors are engaged to the first and second vertebral bodies, respectively, through first and second percutaneous punctures in the subject. A curved brace is installed through a third percutaneous puncture in the subject using an installation instrument. The brace is connected to the anchors by application of fastening tool to the anchors through the first and second punctures.

[0019] In another form of the present invention, a curved brace is installed by swinging the brace through an arc in a plane containing the brace and perpendicular to the axis of curvature of the brace, and passing portions of the brace into passageways in the anchors. The pivot axis of the brace is at a fixed distance from the passageways equal to the radius of curvature of the brace.

[0020] Techniques for minimally invasive surgery are provided in which first and second anchors are inserted through a single incision and engaged to respective ones of first and second vertebrae. A connecting element is positioned proximate the first and second anchors from an entry location into the patient remote from the incision.

[0021] One object of the present invention of the present invention is to provide minimally invasive techniques and instruments for stabilizing a bony structure in an animal subject.

[0022] Related features, aspects, embodiments, objects and advantages of the present invention will be apparent from the following description.

BRIEF DESCRIPTION OF THE DRAWINGS

[0023]FIG. 1 is a perspective view of a brace and an installation instrument for installing the brace according to one embodiment of the present invention.

[0024]FIG. 2 is an enlarged fragmentary section view taken at line 2-2 of FIG. 1 and viewed in the direction of the arrows.

[0025]FIG. 2a is a side elevational view of another embodiment of a brace inserter.

[0026]FIG. 3 is an enlarged fragmentary exploded view of the connection of the brace to a portion of the installation instrument.

[0027]FIG. 3a is an enlarged fragmentary exploded view of another embodiment connection of the brace to a portion of the installation instrument.

[0028]FIG. 4 is an enlarged section view of a portion of the installation instrument taken at line 4-4 of FIG. 1.

[0029]FIG. 5 is an end view, on a smaller scale than FIG. 4, of an outer sleeve comprising a portion of the installation instrument of FIG. 1.

[0030]FIG. 6 is an enlarged section view of a portion of the installation instrument taken through line 6-6 of FIG. 1.

[0031]FIG. 7 is a perspective view on a much smaller scale than FIGS. 4 and 6 of an inner sleeve comprising a portion of the installation instrument of FIG. 1.

[0032]FIG. 8 is a perspective view of a further embodiment of a brave and an installation instrument according to the present invention.

[0033]FIG. 9 is an exploded perspective view of a portion of the installation instrument of FIG. 8.

[0034]FIG. 9a is a section view taken through line 9 a-9 a of FIG. 9.

[0035]FIG. 10 is a side elevational view of the portion of the installation instrument of FIG.

[0036]FIG. 11 is a side elevational view of the brace coupler of the installation instrument of FIG. 8.

[0037]FIG. 11 a is an enlarged detail view of a portion of the brace gripper of FIG. 10.

[0038]FIG. 12 is an enlarged detail view of the portion of installation instrument connected to an indexed brace.

[0039]FIG. 13 is an enlarged view of a trocar and the portion of the installation instrument connected thereto.

[0040]FIG. 14 is an elevational view of an inner sleeve forming a portion of the anchor extension of the installation instrument of FIG. 8.

[0041]FIG. 15 is a right hand end view of the inner sleeve of FIG. 14.

[0042]FIG. 16 is a side elevational view of a first outer sleeve forming a portion of the anchor extension of the installation instrument of FIG. 8.

[0043]FIG. 17 is a side elevational view of a second outer sleeve forming a portion of the anchor extension of the installation instrument of FIG. 8 rotated 90 degrees about its longitudinal axis as compared with the first outer sleeve of FIG. 16.

[0044]FIG. 18 is a perspective view of a guidewire.

[0045]FIG. 19 is a perspective view of a cannulated awl usable in a surgical technique with the installation instrument of the present invention.

[0046]FIGS. 20a and 20 b are perspective views of driver tools usable in a surgical technique with the installation instrument of the present invention.

[0047]FIG. 21 is a side elevational view of a portion of the spinal column and the installation instrument along with a cannula for performing surgical procedures in the disc space.

[0048]FIG. 22 is a top plan view of the instruments of FIG. 21 at the skin level.

[0049]FIGS. 23 and 24 are perspective views of another embodiment of an installation instrument of the present invention usable in a two level stabilization procedure.

[0050]FIGS. 25a-25 g illustrate various steps of a minimally invasive surgical procedure according to present invention.

[0051]FIG. 21 is a side elevational view of a portion of the spinal column and the installation instrument along with a cannula for performing surgical procedures in the disc space.

[0052]FIG. 22 is a top plan view of the instruments of FIG. 21 at the skin level.

[0053]FIGS. 23 and 24 are perspective views of another embodiment of an installation instrument of the present invention usable in a two level stabilization procedure.

[0054]FIGS. 25a-25 g illustrate various steps of a minimally invasive surgical procedure according to the present invention.

DESCRIPTION OF THE ILLUSTRATED EMBODIMENTS

[0055] For the purposes of promoting an understanding of the principles of the invention, reference will now be made to the embodiments illustrated in the drawings and specific language will be used to describe the same. It will nevertheless be understood that no limitation of the scope of the invention is thereby intended. Any such alterations and further modifications in the illustrated devices, and such further applications of the principles of the invention as illustrated herein are contemplated as would normally occur to one skilled in the art to which the invention relates.

[0056] The present invention is directed to instruments and methods for insertion of a brace for connection with anchors engaged to bony parts of the body. Referring to FIG. 1, connecting element or brace 90 is preferably an elongated rod or shaft curved along its length between a connecting end 91 and an insertion end 92 with a radius of curvature R. However, it should be understood that the present invention contemplates that brace 90 can include any configuration known for a rod, implant, or fastener, so long as brace 90 is insertable using installation instrument 20. Further, brace 90 can be elastic or super-elastic member in the form of a cable, band or artificial ligament that used in tethering or other surgical procedures. Non-rigid bracing elements can be positioned with respect to the anchors with a rigid guide member therealong or at the leading end thereof, which can be thereafter removed once the non-rigid bracing element is in its desired position or left in the patient's body. Brace 90 can be percutaneously or non-percutaneously inserted with an installation instrument 20 into passageways of anchors engaged to a bony structure in the body of an animal subject to stabilize the bony structure.

[0057] In the illustrated embodiment, brace 90 is a shaft curved at a single radius R along an arc A, and brace 90 has an axis co-linear with are A. However, it is contemplated that brace 90 can have a curvature that differs from arc A, or can have a curvature that varies or is compounded along its length. The curvature of brace 90 can be defined by any one or any combination of mathematical relationships, including, for example, linear, exponential, logarithmic, trigonometric, geometric, parabolic, quadratic, cubic, hyperbolic, elliptic, or parametric relationships. Brace 90 in FIG. 1 is inserted via the installation instruments of the present invention through passageways 70 a and 70 b of anchors 60 a and 60 b, respectively in order to stabilize adjacent vertebrae V1 and V2. The installation instrument can employ any type of fixed geometric relationship to insert brace 90 into passageways 70 a and 70 b. This fixed geometric relationship can be governed by any one or combination of a pinned joint, a cam, a four-bar linkage, a guide member that provides a path for translational movement of brace 90, or any other mechanical relationship that would occur to those skilled in the art.

[0058] Installation instrument 20 illustrated in FIG. 1 includes a first support arm 22 a and a second support arm 22 b. Support arms 22 a, 22 b are pivotally connected at a proximal end 32 of a brace inserter 24. Brace inserter 24 includes a distal end 33 from which a brace 90 extends. A pivot arm 31 has a straight portion 31 a extending from proximal end 32 to a curved portion 31 b that extends to a brace mounting portion 25 at distal end 33. Inserter 24 is pivotable about a pivot axis P to define a curvilinear arc or axis A. Brace mounting portion 25 includes a brace receiving opening 35 at distal end 33.

[0059] Preferably, brace 90 is supported by mounting portion 25 in receiving opening 35 so that brace 90 is relatively fixed with respect to inserter 24, maintaining alignment of brace 90 along arc axis A during insertion of brace 90. Curved portion 31 b includes a channel 34 extending therealong that receives a brace coupler 36 therein. Preferably, brace coupler 36 is an elongated pin that extends along arc axis A from distal end 33 to a thumb screw 37 adjacent pivot arm 31. As shown in FIG. 3, brace coupler includes an elongated pin having a distal end 36 a that is preferably threaded, and is received within an internally threaded bore 93 formed at brace connecting end 91. It is further contemplated that the pin can be a wire or a flexible rod. Thumb screw 37 is manipulated by the surgeon to connect brace 90 to inserter 24 at brace mounting portion 25. After brace 90 is inserted, the surgeon manipulates thumbscrew 37 to disconnect brace 90 from inserter 24.

[0060] The present invention also contemplates other mechanisms for connecting brace 90 to inserter 24. For example, in FIG. 3a brace coupler 36 includes a draw bar 140 positionable within channel 34. Bar 140 has a distal end 142 with a pair of opposed jaws 143 forming a mouth 145. Each jaw 143 includes a tooth 144 projecting therefrom towards the opposing jaw. Brace 90′ is the same as brace 90, except brace 90′ has a connecting end 91′ with a connecting post 94 extending therefrom.

[0061] Connecting post 94 is tapered from connecting end 91′ to tip 96, and is configured to mate with jaws 143 in mouth 145 when jaws 143 are clamped around connecting post 94. Connecting post 94 includes a recess 95 formed adjacent connecting end 91′ configured to receive teeth 144 therein. In order to clamp connecting post 94, a proximal end of draw bar 140 extends from inserter 24, as shown in FIG. 1 with respect to coupler 36, and has a threaded thumbscrew engaged thereto. The jaws are actuated and clamped around connecting post 94 by threading the thumbscrew in an appropriate direction to draw bar 140 into channel 34. Jaws 143 are pressed towards one another and teeth 144 are received into recess 95, thereby connecting brace 90′ to inserter 24. Preferably, connecting post 94 is indexed so that brace 90′ can only be coupled to inserter 24 with brace 90′ extending along axis A. This indexing can be accomplished by providing two recesses 95 each sized to receive tooth 144 and positioned on post 94 such that brace 90′ can only be coupled via teeth 144 if brace 90′ is oriented along axis A.

[0062] Inserter 24 has a bottom surface 25 a that is preferably curved along axis A to facilitate smooth percutaneous insertion of brace 90. Further, curved portion 31 b has at mounting portion 25 a thickness t1 between bottom surface 25 a and a top surface 25 b. The thickness increases along the length of curved portion 31 b of pivot arm 31 in a smooth taper to a thickness t2 adjacent the straight portion 3 la. Thickness t2 is preferably greater than thickness t1, facilitating percutaneous insertion and withdrawal of curved portion 31 b while minimizing damage and trauma to the surrounding tissue.

[0063] Support arms 22 a and 22 b have proximal end portions adjacent axis P with tool bores 26 a and 26 b, respectively, for receiving a driving tool therethrough to manipulate anchors 60 a and 60 b, respectively, as described further below. In the illustrated embodiment, support arm 22 a includes an upper post 28 a having a channel 23 a extending upwardly to the proximal end portion and communicating with tool bore 26 a. An anchor extension 30 a is mounted in channel 23 a via a thumbscrew 27 a threadedly received in a threaded aperture 29 a that extends through upper post 28 a and anchor extension 30 a. Anchor extension 30 a is mounted at its lower or distal end to anchor 60 a. Similarly, support arm 22 b includes an upper post 28 b having a channel 23 b communicating with tool bore 26 b. An anchor extension 30 b is mounted in channel 29 b via a thumbscrew 27 b threadedly received in a threaded aperture (not shown) extending through upper post 28 b and anchor extension 30 b. Anchor 30 b is mounted at its lower or distal end to anchor 60 b. The present invention also contemplates that upper post 28 a and anchor extension 30 a, and similarly upper post 28 b and anchor extension 30 b, are not separate components but rather are formed as a unit to which brace inserter 24 is pivotably attached.

[0064] Inserter 24 is pivotally connected to upper posts 28 a and 28 b of support arms 22 a and 22 b, respectively. As shown in FIG. 2, a cross-section taken at line 2-2, inserter 24 is positioned between support arms 22 a and 22 b. Upper post 28 a has a cylindrical portion 46 a with a first flanged bushing 47 a extending therefrom. Upper post 28 b has a cylindrical portion 46 b with a second flanged bushing 47 b extending therefrom. Bushings 47 a and 47 b are rotatably received in a through-hole 39 that extends through pivot arm 31. Bushings 47 a and 47 b define a through opening 48 for receiving a pin 49 therein to secure posts 28 a and 28 b to pivot arm 31. Preferably, pin 49 is threaded along a portion of its length to engage internal threads in bushing 47 a, and the head of pin 49 sits within a countersink formed in cylindrical portion 46 b at bushing 47 b to maintain clearance of bore 26 b.

[0065] An alternate form of pivot arm 31 for pivoting rod inserter 24 is illustrated in FIG. 2a and designated as rod inserter 24′, and like elements between inserter 24 and 24′ are designated with like reference numerals. Inserter 24′ has pivot arm 122 extending from curved portion 31 b to a proximal end 123. A handle 128 is positioned adjacent brace mounting portion 25 on pivot arm 122 to facilitate percutaneous insertion of brace 90 and withdrawal of the instrument by the surgeon. A pair of arms 124, 126 adjacent proximal end 123 form a passage therebetween. The passage is configured to receive support arms 22 a, 22 b between arms 124 and 126. Holes 125 and 127 formed through arm 124 and 126, respectively, are provided for a connection mechanism to pivotally connect inserter 24′ to support arms 22 a and 22 b.

[0066] Referring now to FIG. 4, details of anchor extensions 30 a and 30 b and anchors 60 a and 60 b (hereinafter collectively referred to as anchor extension 30 and anchor 60) will now be described. In FIG. 4, anchor 60 is shown fragmentarily as a bone screw 61 with its head 63 mounted in a receiver or connector. In FIG. 1, screws 61 a and 61 b are shown cannulated with central passage 85 a and 85 b, respectively; however, non-cannulated screws 61 are also contemplated.

[0067] In the illustrated embodiment, the receiver or connector is a yoke 68 that defines a passageway 70 for receiving brace 90 therethrough and a set screw 76 to secure brace 90 in yoke 68. Yoke 68 is mountable to anchor extension 30 before and during percutaneous placement and securement of anchor 60 to the bony structure. Anchor extension 30 includes an outer sleeve 40 and an inner sleeve 50 disposed within a bore 45 through outer sleeve 40. Inner sleeve 50 defines a bore 51 therethrough that communicates with the channel and tool bore 26 of the upper post 28 to which inner sleeve 50 is attached (FIG. 1). Distal end 53 of inner sleeve 50 includes a lip 52 extending radially therearound projecting into inner bore 51. Lip 52 retains set screw 76 on inner sleeve 50 with screw 76 at least partially threaded into yoke 68, thereby mounting anchor 60 on anchor extension 30.

[0068] Screw 61 has bone engaging threads formed on shank 62 and a head 63 that includes tool opening 64, such as a hex opening or the like, configured to receive a driving tool. In a preferred form, anchor 60 is a multi-axial screw assembly that has yoke 68 pivotably coupled to head 63 of screw 61. However, the use of an anchor 60 that does not include a screw having multi-axial capabilities is not precluded by the present invention. As is known in the art, screw 61 is capable of being rotated within yoke 68 to assume a plurality of angles between axes L1 and L2. Further, screw 61 can be rotated 360 degrees about axis L at any one of the angular positions between axis L1 and L2. One specific example of a multi-axial screw having application with the present invention is described in U.S. Pat. Nos. 5,797,911 and 5,879,350, each of which is incorporated herein by reference.

[0069] In the illustrated example, anchor 60 includes a connector in the form of a generally cylindrical yoke 68 having passageway 70 therethrough for receiving brace 90. Head 63 of screw 61 is received within a bowl 69 formed at the bottom of yoke 68. A groove 67 is formed in bowl 69, and a collar 65 is retained in bowl 69 via groove 67. Collar 65 captures screw 61 in yoke 68, and is configured to mate with head 63 to allow multi-axial orientations of screw 61 as described above. A cap 66 is positioned over head 63 and limits upward displacement of screw 61 in yoke 68.

[0070] Yoke 68 includes arms 71 extending upwardly from bowl 69 on opposite sides of passageway 70. Arms 71 have internal threads 72 configured to mate with external threads 77 on set screw 76. Set screw 76 has upper tool engaging portion 78 having tool dimension d2 and a lower tool engaging portion 79 having tool dimension d1 that is less than d2. Set screw 76 has a shoulder 80 that is supported on inner sleeve 50 by lip 52. Set screw 76 is positioned with shoulder 80 on lip 52 by threading external threads 77 past lip 52. In FIG. 4, set screw 76 is partially threaded into internal threads 72 of yoke 68 in order to couple anchor 60 to anchor extension 30. Upper tool engaging portion 78 has a reduced thickness portion 81 where it joins lower tool engaging portion 79. Thus, in this embodiment, set screw 76 is a break-off type set screw which severs at reduced thickness portion 81 when a predetermined threshold torque is applied at upper tool engaging portion 78, thus allowing a desirable and uniform securing force to be applied to brace 90 with each of the set screws 76. Another advantage is that set screw 76 can be released from anchor extension 30 when set screw 76 is severed.

[0071] Yoke 68 is received within recess portion 42 at distal end 41 of outer sleeve 40. As shown in FIG. 5, an end view of outer sleeve 40, recess 42 is shaped with a generally cylindrical wall with a couple of flat surface to conform to the outer perimeter of yoke 68 at upper end surfaces 73. Upper surfaces 73 of arms 71 are held firmly against recessed surface 44 by set screw 76, which is releasably coupled to yoke 68 and inner sleeve 50, by drawing yoke 68 into recess 42 via inner sleeve 50. Anchor 60 is mounted to anchor extension 30 and held in a fixed position relative to anchor extension 30. Axis L3 of anchor extension 30 is aligned with axis L1 of bone screw 61 when a guidewire, such as guidewire 280 of FIG. 18, or a tool, such as tool 100 or 100′ of FIGS. 20 and 20b is inserted into screw 61 to maintain anchor 60 in this aligned position.

[0072] Referring to FIGS. 6 and 7, inner sleeve 50 and its connection with outer sleeve 40 will be further described. Inner sleeve 50 includes lower cylindrical tubular body portion 53. Fingers 54 extend from body portion 53 to upper end 55 of inner sleeve 50. Fingers 54 include retainers 56 adjacent upper end 55. A pin or nub 58 is positioned on and extends from the outer surface of each finger 54. Outer sleeve 40 includes upper paired holes 57 a and lower paired holes 57 b, which serve as catches. As shown in FIG. 6, nubs 58 are positionable within catches 57 a or 57 b formed in outer sleeve 40 to hold inner sleeve 50 relative to outer sleeve 40. Retainers 56 contact upper end 46 of outer sleeve 40 when nubs 58 are positioned in lower catches 57 b. Retainers 56 limit the depth of insertion of inner sleeve 50 into bore 45 of outer sleeve 40. Retainers 56 also facilitate insertion and withdrawal of inner sleeve 50 relative to outer sleeve 40 by providing the surgeon means to grasp fingers 54 and squeeze.

[0073] Finger 54 can be deflected towards one another as indicated by arrows P in order to disengage nubs 58 from catches 57 a and 57 b, thus allowing rotation and axial translation of inner sleeve 50 in outer sleeve 40. Outer sleeve 40 includes notches 59 formed at upper end 46 on opposite sides of outer sleeve 40 between respective ones of the paired catches 57 a and paired catches 57 b. Notches 59 allow inner sleeve 50 to be positioned in outer sleeve 40 with nubs 58 at a depth approximating the location of catches 57 a and 57 b without deflecting fingers 54. Fingers 54 can then be pressed together to withdrawal nubs 58 from notches 59, allowing inner sleeve 50 to be rotated and nubs 58 positioned in the desired paired catches 57 a or paired catches 57 b.

[0074] With nubs 58 positioned in lower catches 57 b, set screw 76 extends into recess portion 42 of outer sleeve 40 enough to allow anchor 60 to be mounted on extension 30 by threading set screw 76 partially into yoke 68. Nubs 58 can then be positioned in upper catches 57 a, retracting yoke 68 into recessed portion 42 of outer sleeve 40 to hold anchor 60 firmly in place as shown in FIG. 4 and described above. Anchor 60 can thus be pre-assembled with anchor extension 30 before engaging anchors 60 to the bony structure, allowing the assembled anchor 60 and anchor extension 30 to be positioned percutaneously together in a minimally invasive approach to the bony structure. However, it is also contemplated that anchor extension 30 can be mounted on an anchor 60 that is already engaged to the bony structure.

[0075] Referring now to FIGS. 8 and 9, another embodiment of an installation instrument is illustrated. In FIG. 9, anchor extensions 230 are not illustrated. Anchor extensions 230 include an inner sleeve 240 that is received proximally within outer sleeve 250 in a manner similar to that described above with respect to anchor extension 30. The inner sleeve 240 and outer sleeve 250 are further illustrated in FIGS. 14-17, and are described in further detail below.

[0076] Installation instrument 220 includes a brace inserter 224 having a first support arm 222 a and a second support arm 222 b. Support arms 222 a, 222 b come together and are fixedly connected at a proximal end 232 of a pivot arm 231. Referring now further to FIGS. 9a and 10, pivot arm 231 includes a distal end 233 from which brace 290 extends. Brace inserter 224 includes a brace mounting portion 225 adjacent distal end 233 for securing a brace, such as brace 290, thereto. Brace 290 is similar to brace 90, and includes a connecting portion 291 as described further below. Brace inserter 224 is pivotable about a pivot axis P to define a curvilinear arc or axis A. Pivot arm 231 of brace inserter 224 is preferably curved along curved portion 231 b to follow axis A and facilitate smooth percutaneous insertion and withdrawal of pivot arm 231. As shown in FIG. 9a, brace mounting portion 225 includes a brace receiving opening 235 extending proximally from distal end 233.

[0077] Pivot arm 231 includes a channel 234 extending from distal end 233 therealong towards proximal end 232. Channel 234 receives a brace coupler 236 therein that is secured to inserter 224 by a nut 239 and pin 228. For the purposes of clarity, nut 239 and brace coupler 236 are shown displaced from channel 234 except at distal end 233. Preferably, brace coupler 236 is an elongated flexible member that extends with arc axis A from distal end 233 through nut 239 to a set screw 237 adjacent proximal end 232. Coupler 236 is pivotably coupled to inserter 224 at brace mounting portion 225 via pin 228. Set screw 237 is threadingly received in a threaded opening formed in nut 239. Brace mounting portion 225 also includes stop pin 229 extending therethough in communication with brace receiving opening 235.

[0078] Referring now further to FIGS. 11-12, brace 290 is positionable in brace receiving opening 235 so that brace 290 is relatively fixed with respect to inserter 224 by brace coupler 236, maintaining alignment of brace 290 along arc axis A during insertion of brace 290. Brace coupler 236 includes gripping portion 270 at its distal end for gripping brace 290. Gripping portion 270 has through-hole 272 receiving pin 228 therethrough and rotatably coupling gripping portion 270 at brace mounting portion 225. Gripping portion 270 further includes a tooth 274 extending therefrom at its distal end 271. A notch 276 extends proximally from tooth 274.

[0079] Brace 290 has a connecting end 291 with a connecting post 294 extending therefrom. Preferably, connecting post 294 is tapered from connecting end 291 to tip 296, and has a recess 297 with a length and depth configured to receive tooth 274 at the end of the recess 297 adjacent tip 296 and stop pin 229 at the end of recess 297 adjacent connecting end 291. Stop pin 229 contacts brace 290 in recess 297 to limit the depth of insertion of brace 290 into opening 235.

[0080] In one aspect of the invention, brace 290 is indexed by providing a single recess 297 at a predetermined location on post 294. Post 294 cannot be inserted properly into channel 235 unless stop pin 229 is received in recess 297, thus ensuring an orientation of brace 290 with respect to inserter 224 that is determined by the position of recess 297 with respect to stop pin 229. Preferably, the position of recess 297 is such that it is located with respect to gripping portion 270 so that the radius of curvature of brace 290 extends from inserter 224 along arc axis A. This ensures accurate positioning and orientation of brace 290 with respect to anchors 60 during installation of brace 290.

[0081] In order to grip brace 290 when connecting portion 291 is placed into opening 235, gripping portion 270 is rotated downwardly about pin 228 in the direction of arrow R by drawing brace coupler 236 proximally via threading of set screw 237 in a first direction with respect to lock nut 239. Set screw 237 is threaded in an opposite second direction to push brace coupler 236 distally and therefore bend coupler 236, rotating tooth 274 about pin 228 in the direction opposite arrow R out of recess 297 thereby releasing brace 290.

[0082] Referring back to FIGS. 8 and 9, support arms 222 a and 222 b have through-holes 223 a, 223 b for receiving a clamping mechanism 221. Clamping mechanism 221 draws arms 222 a, 222 b towards one another to pivotably secure anchor extensions 230 a, 230 b therebetween. Pivot nuts 225 a and 225 b are positionable in through holes 223 a and 223 b, respectively. A clamping bar 225 extends between arms 222 a and 222 b, and has threaded bores at each end that allow bar 225 to be secured to and clamp arms 222 a, 222 b via threaded fastener 226 and clamping knob 227 having a threaded stem 227 a. Clamping knob 227 is manipulated by the surgeon to secure or release extensions 230 a and 230 b from arms 222 a and 222 b.

[0083] In the illustrated embodiment, pin 260 a is press fit into opening 262 a of arm 222 a. Anchor extension 230 a is rotatably mounted on support arm 222 a via pin 260 a. Similarly, anchor extension 230 b is rotatably mounted on support arm 222 b via pin 260 b press fit into opening 262 b of arm 222 b. Other techniques for securing pins 260 a, 260 b and mounting extensions 30 a, 30 b thereto are also contemplated as would occur to those skilled in the art. Each arm 222 a, 222 b can be provided with a stop bar 264 a, 264 b extending therefrom towards the other support arm 222 b, 222 a, respectively. Stop bars 264 a and 264 b limit rotation of instrument 220 along axis A when stop bars 264 a, 264 b contact a corresponding one of the extensions 230 a, 230 b.

[0084] Referring now to FIGS. 14-17, anchor extensions 230 that coupled to inserter 224 will now be described in further detail. These anchor extensions 230 are illustrated in an assembled condition in FIG. 8. It should be noted that second outer sleeve 240 b of FIG. 17 is illustrated rotated 90 degrees about its longitudinal axis as compared with the orientation of the elevational view of first outer sleeve 240 a of FIG. 16.

[0085] Although anchors are not shown in FIG. 8, anchor extension 230 a can have mounted thereon at its lower or distal end a first anchor, such as anchor 60 a described above. Similarly, anchor 230 b can have mounted at its lower or distal end a second anchor, such as anchor 60 b, described above. Anchor extensions 230 a, 230 b, collectively referred to as anchor extensions 230, each include outer sleeve 240 and an inner sleeve 250 disposed within a bore 245 through outer sleeve 240. Inner sleeve 250 defines a bore 251 therethrough that allows tools to extend to the anchor. Distal end 253 of inner sleeve 250 includes a lip 252 extending radially therearound projecting into inner bore 251. Lip 252 supports a set screw, such as set screw 76 described above, on the distal end of inner sleeve 250.

[0086] Yoke 68 is preferably received within end portion 242 at distal end 241 of outer sleeve 240. As shown in FIG. 16, end portion 242 has a U-shaped opening that is alignable with passageway 70 to accommodate insertion of brace 290 therethrough. The arms 244 of end portion 242 are alignable with the arms 71 of yoke 68, receiving arms 71 therein, firmly securing anchor 60 onto anchor extension 230 during insertion of the anchor.

[0087] The positioning of inner sleeve 250 into outer sleeve 240 will be further described, although those skilled in the art will appreciate that anchor extension 30 and anchor extension 230 are similar in many respects. Inner sleeve 250 includes lower gripping elements or fingers 254 that include circular relief portions 277 therebetween to allow flexing of fingers 254. Inner sleeve 250 further includes upper notch 256 and lower notch 256′ between fingers 254 and upper end 255. Outer sleeve 240 includes a plunger-type spring biased retainer 257 extending therein adjacent bore 245 having a cross bar 258 extending transversely from a plunger 259. Cross bar 258 is selectively positionable in a desired one of the notches 256 and 256′ to hold inner sleeve 250 relative to outer sleeve 240. Shoulder 261 limits the depth of travel of inner sleeve 250 distally into bore 245 of outer sleeve 240. When cross bar 258 is in upper notch 256, set screw 76 of anchor 60 can be threaded onto or pushed between fingers 254 at distal end 253, where set screw 76 is retained thereon by lip 252.

[0088] If not already secured to set screw 76, yoke 68 can then be at least partially threaded onto set screw 76. Movement of inner sleeve 250 relative to outer sleeve 240 is facilitated by depressing plunger 259 to lift cross bar 258 out of upper notch 256. Inner sleeve 250 is moved proximally to position cross bar 258 in lower notch 256′, drawing yoke 68 between the arms 244 and against end portion 242 with passage 70 aligned with the U-shaped opening between the arms 244. Axis L3 of anchor extension 230 is aligned with axis L1 of bone screw 61 when a guidewire or a tool, such as tool 100 or 100′ of FIGS. 20 and 20b is inserted into screw 61 to maintain anchor 60 in this aligned position. An alignment pin 263 of inner sleeve 250 is received in slot 249 of outer sleeve 240 to ensure and maintain proper alignment of inner sleeve 250 in outer sleeve 240.

[0089] The assembly of anchor extensions 230 a and 230 b to one another and also to inserter 224 will now be described. Each anchor extension 230 includes passage 248 through outer sleeve 240 adjacent the proximal end 243. A coupling pin 249 a is press fit or otherwise secured in passage 248 a on the side of anchor extension 230 a adjacent anchor extension 230 b. After anchor extensions 230 a and 230 b and anchors 60 a and 60 b are secured to bony structure, anchor extensions 230 a and 230 b are manipulated through the skin and tissue to place pin 249 a into the portion of passage 248 b adjacent anchor extension 230 a. Inserter 224 is secured to anchor extensions 230 a and 230 b by placing pin 260 a in a portion of passage 248 a of first extension 230 a opposite pin 249 a, and pin 260 b in a portion of passage 248 b of second extension 230 b opposite pin 249 a. Pins 260 a and 260 b are rotatably received in the passages 248 a and 248 b, respectively, and anchors extension 230 a and 230 b are secured to support arms 222 a and 222 b via clamping mechanism 221. Bores 251 a and 251 b of inner sleeves 250 a and 250 b remain substantially unobstructed for access to anchors 60 a and 60 b when instrument 220 is assembled.

[0090] Techniques using the above described installation instruments 20, 220 will now be described. The present invention contemplates that placement of anchors 60 into the bony structure can be completed without an anchor extension 30 or 230 mounted thereto, and anchor extension 30 or 230 is thereafter mounted on the anchor 60 engaged to the bony structure. Other techniques contemplate that the anchor 60 is mounted on anchor extension 30 or 230, and anchor extension 30 or 230 and anchor 60 are placed through an open incision, micro-incision, a tube or cannula, or directly through the skin and tissue of the animal subject to engage anchor 60 to a bony structure, such as the pedicles of vertebrae V1 and V2 as shown in FIG. 1.

[0091] The surgical techniques of the present invention can employ any type of known imaging system to determine and locate optimum placement and orientation of the anchors in the bony structure and, if necessary, to locate skin locations for percutaneous puncture entry of the anchors. Image guided systems useful in practicing the invention and in placing anchors 60 are known in the art. Examples of image guided technology are provided in U.S. Pat. No. 5,772,594; U.S. Pat. No. 5,383,454; U.S. Pat. No. 5,851,183; U.S. Pat. No. 5,871,445; U.S. Pat. No. 5,891,034; and PCT Publication WO 99/15097, each of which is incorporated herein by reference in its entirety. The STEALTHSTATION® or ION™ systems, sold by Medtronic Surgical Navigation Technologies, Inc. can further be used with the present invention for pre-operative planning and image guided navigation of anchor placement and installation of brace 90.

[0092] Other techniques for locating and placing anchors 60 into the bony structure are also contemplated herein as would occur to those skilled in the art. For example, a CT scan or x-ray can be used for pre-operative planning of anchor positioning and orientation. Anchor insertion can be monitored using any known viewing instrument or apparatus. Another example contemplates anchor placement through a cannula or sleeve inserted through the skin that forms a working channel to the anchor location. Anchor placement into the bony structure can be monitored endoscopically or microscopically through the cannula.

[0093] In one specific technique, a guidewire, such as guidewire 280 of FIG. 18, of sufficient length is inserted percutaneously and anchored to the bony structure. The guidewire is coupled to a trackable instrument that is tracked via an image guided surgical system that generates a display on a computer monitor. Further examples of such instruments and systems are described in further detail in PCT Publications WO 99/15097 and WO 99/26549, each of which is incorporated herein by reference in its entirety. With the guidewire secured at the appropriate location on the bony structure, various instruments for preparing and inserting the screw into the bony structure can be guided by the guidewire. The preparation and insertion can be monitored via a tracking instrument coupled to the various preparation and insertion instruments.

[0094] Various instruments can be used to prepare the surgical site for anchor insertion. For example, in FIG. 19 there is illustrated a cannulated awl 300 that is inserted over the guidewire to prepare the bony structure for screw insertion. Awl 300 has a bore 306 extending between distal end 303 and proximal end 302 that allows awl 300 to be inserted over the guidewire. Awl 300 is configured at proximal end 302 to engage a driving instrument, which can also include a tracking instrument to monitor insertion depth. Awl 300 has shaft 304 extending to distal end 303. A cutting head 307 at distal end 303 prepares a hole in the bony structure for the anchor.

[0095] After determining the desired position and orientation of guidewire 280 in the bony structure and the skin location for puncture entry and preparing the screw hole, a cannulated anchor 60 mounted on anchor extension 30 or 230 can be placed over the guidewire and advanced, for example, through the skin and tissue directly, through an incision, or through a cannula to the prepared hole. A driving tool, such as cannulated driving tool 100′ shown in FIG. 20a, is used to threadingly engage anchor 60 to the bony structure. Cannulated tool 100′ includes bore 106′ extending between proximal end 102′ and distal end 103′. Distal end 103′ includes an engaging portion 107′ to mate in tool engagement recess 64 of screw 61. Tool 100′ is placed over the guidewire and through the tool bores of the anchor extensions 30, 230 to drive the cannulated screw 61 into the bony structure.

[0096] It is further contemplated that if the technique does not employ a guidewire, a driving tool 100 of FIG. 20b can be inserted through the tool bores of the anchor extensions 30, 230 to screw 61. Tool 100 includes proximal end 102 and a shaft 104 extending to distal end 103. Proximal end 102 is preferably configured to engage a wrench or handle to facilitate application of a driving force with tool 100. Distal end 103 includes a lower engaging portion 107 having a length configured to mate in tool engagement recess 64 of screw 61 to drive screw 61 into the bony structure.

[0097] Anchor extension 30, 230 follows anchor 60 towards the bony structure as anchor 60 is driven therein with driving tool 100 or 100′. Tool 100 is then withdrawn from the tool bore, and if necessary, the guidewire is also withdrawn. In embodiments of anchor 60 having a multi-axial screw, yoke 68 and anchor extension 30, 230 are pivotable about head 63 by manipulating anchor extension 30, 230 in the skin and tissue to the desired position.

[0098] With anchors 60 a and 60 b secured to the bony structure, passageways 70 a and 70 b are aligned to receive brace 90. For instrument 20, upper posts 28 a and 28 b are mounted on anchor extensions 30 a and 30 b using thumb screws 27 a and 27 b, respectively, aligning passageways 70 a and 70 b. With anchors 60 employing a multi-axial screw, the anchor extensions 30 a and 30 b can be manipulated into the desired position for connection with upper posts 28 a and 28 b. For instrument 220, anchor extensions 230 a and 230 b are manipulated to place pin 249 a in passage 248 b, aligning passageways 70 a and 70 b. Support arms 222 a and 222 b are secured to anchor extensions 230 a and 230 b with clamping mechanism 220. If anchor 60 does not have multi-axial capabilities, the orientation of the anchor extensions required to connect the inserter thereto is accounted for during the determination of the orientation and positioning anchors 60 a and 60 b into the bony structure.

[0099] Brace 90, 290 is fixed on inserter 24, 224 and readied for percutaneous insertion into passageways 70 a and 70 b of anchors 60 a and 60 b, respectively. Preferably, brace 90, 290 is curved and has a radius of curvature equal to the distance between passageways 70 a, 70 b and pivot axis P. Inserter 24, 224 swings about pivot axis P to move brace 90 in a forward direction along arc axis A and thereby introducing pointed end of brace 90, 290 into the subject's body towards the aligned passageways 70 a and 70 b. Brace 90, 290 and inserter 24, 224 are further pivoted to pass portions of brace 90 through passageways 70 a and 70 b of anchors 60 a and 60 b.

[0100] As discussed above, it is preferred that brace is indexed so that it can be secured at a predetermined orientation onto the installation instrument 20, 220. This ensures alignment of brace 90, 290 along the insertion path of the installation instrument and through the passageways of anchors 60 a and 60 b. In a further form, trocar 390, as shown in FIG. 13, can be used to puncture skin and tissue along the insertion path and facilitate insertion of brace 90, 290 in a percutaneous procedure. Trocar 390 has a connecting end 394 identical to that of brace 290. However, trocar 390 has a short shaft 392 extending to puncture tip 398. Puncture tip 398 has a sharp point 399 to facilitate insertion and create a pathway through skin and tissue of the patient.

[0101] Brace 90, 290 is placed through the passageways of anchors 60 a and 60 b to the desired position, which can be confirmed radiographically or with any know imaging technique. Set screws 76 a and 76 b of each anchor 60 a and 60 b are driven downward to contact brace 90, 290. A driving tool is placed through the tool bores of the installation instruments 20, 220 to engage either the upper tool engagement portion 78 a, 78 b or lower tool engagement portion 79 a, 79 b and drive set screw 76 a, 76 b downwardly, tightening it against brace 90, 290 until set screw 76 a, 76 b is firmly seated thereagainst. Inserter 24, 224 can then be uncoupled from brace 90, 290 and removed from the subject by swinging inserter 24, 224 back along arc axis A. A tool is positioned in upper tool engagement portion 78 a, 78 b to break off the upper portion of the set screw 76 a, 76 b upon application of the requisite torque, releasing the anchor extension 30 a, 30 b from anchor 60 a, 60 b and allowing removal of extensions 30, 230 from the subject.

[0102] The surgeon may also desire to initially seat set screw 76 a, 76 b using a tool in upper tool engagement portion 78 a, 78 b and apply sufficient torque to severe the break-off portion of set screw 76 a 76 b before uncoupling brace 90, 290. In an alternate form, the driving force that is applied to set screw 76 a, 76 b could force shoulder 80 a, 80 b through lip 52 a, 52 b, deflecting lip 52 a, 52 b downward to release set screw 76 a, 76 b from inner sleeve 50 a, 50 b of instrument 20 or deflect fingers 154 a, 154 b outward to release set screw 76 a, 76 b from inner sleeve 150 a, 150 b of instrument 220.

[0103] In one specific application of the present invention, brace 90 is installed to stabilize a first vertebra V1 and second vertebra V2 after placement of one or more implants I into disc space D as shown in FIG. 21. The method includes removing the intervertebral disc from the space between first and second vertebral bodies through one percutaneous puncture in the subject. An implant I is introduced into the disc space. Implant I is preferably one or more interbody fusion devices or the like as is known in the art. The first and second anchors 60 a and 60 b and anchor extensions 30 a and 30 b are engaged to the first and second vertebral bodies, respectively, through second and third percutaneous punctures in the subject as described above. If desired, the anchor extensions 30 can be manipulated by the surgeon to apply a load to compress or distract the vertebrae prior to installing brace 90. Brace 90 is installed through a fourth percutaneous puncture in the subject using installation instrument 20 and secured to anchors 60 a, 60 b as described above. In some surgical procedures, it may be desirable to insert one or more additional braces to stabilize the bony structure using the above described installation instrument and techniques.

[0104] The present invention has application in further minimally invasive and open techniques for placing interbody fusion device into a disc space between adjacent vertebrae. For example, transforaminal, posterior, and posterior-midline approaches to the disc space are contemplated for placement of one or more implants or interbody fusion device in the disc space. Examples of such techniques are described in U.S. patent application Ser. No. 09/692,932, filed on Oct. 20, 2000. The present invention further has application for engagement of one or more rigid elongated connecting elements to one or more anchors for stabilization of a motion segment without fusion of the motion segment. The present invention also has application for engagement of one or more flexible elongated connecting elements to one or more anchors for stabilization of a motion segment without fusion of the motion segment.

[0105] As shown in FIG. 21, installation instrument 20 is mounted on anchors 60 a and 60 b engaged to vertebrae V1 and V2, respectively. Brace 90 is shown before percutaneous insertion. A cannula 110 is percutaneously inserted to a position adjacent disc space D1. As shown in FIG. 22, a plan view taken at skin surface S, first and second anchor extensions 30 a, 30 b and brace 90 are positioned on one side of midline M of the spine. Cannula 110 is positioned on the opposite side of midline M. One or more interbody fusion devices, bone graft material, or other material or implants are placed in the disc space. The adjacent vertebrae V1 and V2 are then stabilized by installing brace 90 as described above. Thus, a minimally invasive surgical procedure of the present invention contemplates interbody fusion and stabilization of the adjacent vertebrae to be accomplished with four entry holes or punctures through skin S.

[0106] The installation instrument of the present invention can also be used to install braces on both sides of midline M of the spine. The installation instrument can also be used to install multiple braces at one or more levels of the spine. The present invention can be used to stabilize adjacent vertebra in conjunction with any minimally invasive or open surgical techniques for placement of one or more interbody fusion devices into a disc space as would occur to those skilled in the art. For example, one or more interbody fusion devices or intervertebral spacers may be inserted into the disc space via an anterior approach. Examples of anterior approaches are described in PCT International Publication No. WO 97/30666; pending U.S. patent application Ser. No. 09/287,917; and pending U.S. patent application Ser. No. 09/498,426 filed on Feb. 4, 2000; each of which is incorporated herein by reference in its entirety. Further, the present invention may also be used to stabilize adjacent vertebrae, or any other bony structure, without placement of fusion devices or implants in the bony structure.

[0107] It is further contemplated that brace 90 may be installed and secured to anchors engaged in respective ones of three vertebrae using an installation instrument such as the one illustrated in FIGS. 23-24 and designated generally at 320. Instrument 320 is similar to and functions principally the same as instrument 220, except instrument 320 has a size and configuration adapted for this two level stabilization procedure. In this embodiment, three anchors that are like anchor 60 (not shown) are engageable to respective ones of three vertebrae or other bony structure using any of the above described techniques. Three anchor extensions 330 a, 330 b, 330 c each include outer sleeves 340 a, 340 b, 340 c and inner sleeves 350 a, 350 b, 350 c that are substantially the same as outer sleeve 240 and inner sleeve 250 of instrument 220. Anchor extensions 330 are each mounted on a corresponding one of the three anchors. After the anchors are engaged to the bony structure, the three anchor extensions 330 a, 330 b, 330 c are manipulated through the skin and coupled to one another in the same manner as described above with respect to anchor extensions 230 a and 230 b. Support arms 322 a, 322 b of inserter 324 are then rotatably mounted on the anchor extensions 330 a, 330 b, and 330 c and clamped via clamping mechanism 321. Support arms 322 a, 322 b and clamping mechanism 321 are similar to support arms 222 a, 222 b and clamping mechanism 221 of installation instrument 220 except that each is sized to accommodate three anchor extensions 330 therebetween. An indexed brace 490 is similar to brace 290 and has a sufficient length for a two-level stabilization procedure. Brace 490 is secured to pivot arm 331 and then inserted through the passageways of the anchors as described above with respect to installation instrument 220.

[0108] With reference to FIGS. 25a-25 g, further description of minimally invasive surgical techniques will be provided. It should be understood that although surgical techniques described with reference to FIGS. 25a-25 g make specific reference to installation instrument 220 with brace inserter 224 and anchor extensions 230, the other embodiment installation instruments discussed herein are also contemplated with such techniques. Furthermore, thought the technique is described with reference to first and second vertebrae V1 and V2, it should be understood that the techniques described herein have application with other bony structures and elements of the body.

[0109] In FIG. 25a an incision H1 has been made through the skin and tissue of the patient in order to provide access to disc space D1 between vertebrae V1 and V2. In the illustrated embodiment, incision H1 is made for a postero-lateral approach to the disc space, although transforaminal, posterior, and posterior-midline, lateral, antero-lateral and anterior approaches to the disc space are also contemplated. A retractor sleeve 500 is positioned through incision H1 to provide access to disc space D1 for performing surgical procedures in and/or adjacent to the disc space and vertebrae V1 and V2. Surgical procedures such as a laminotomy, laminectomy, foramenotomy, facetectomy and/or discectomy can be performed through retractor sleeve 500. A spinal fusion device, artificial disc or other interbody device indicated by implant I can also be inserted in the disc space through retractor sleeve 500. Examples of retractor sleeves and surgical approaches to the spinal disc space for inserting an implant or fusion device in the disc space through a retractor sleeve are provided in U.S. patent application Ser. No. 09/692,932 filed on Oct. 20, 2000 and also in U.S. patent application Ser. No. 09/815,963 filed on Mar. 13, 2001, each of which is incorporated herein by reference in its entirety.

[0110] In one specific procedure, it is contemplated that a needle having a stylet is inserted through the skin and tissue of the patient and entered into the bone at the desired location. The stylet is removed from the needle, and a guide wire inserted through the central needle bore and anchored to the bone. The needle is then withdrawn, and sequential dilation of the tissue is completed over the guidewire using one or more tissue dilators of increasing size. The retractor sleeve is then placed over the last inserted dilator.

[0111] Such procedures in disc space D1 through retractor sleeve 500 are considered to be minimally invasive because the cutting and retraction of muscle and soft tissue required to access disc space D1 and vertebrae V1 and V2 is minimized. The muscle and other tissue below skin S is sequentially dilated or retracted through incision H1 to separate the muscle and tissue and provide a pathway for insertion of retractor sleeve 500. Alternatively, retractor sleeve 500 can be configured to retract the muscle and tissue through incision H1 to accommodate its insertion and also after its insertion. Thus, the size of incision H1 is minimized to the size needed to accommodate retractor sleeve 500. For example, in one surgical technique, incision H1 has a length in the direction of the central axis of the spinal column that is the same as the cross sectional dimension as retractor sleeve 500. In one embodiment, incision H1 is 18 millimeters or less. In another embodiment, incision H1 is 16 millimeters or less. In a further embodiment, incision H1 is 14 millimeters or less.

[0112] As shown in FIG. 25b, once the desired surgical procedures through retractor sleeve 500 have been completed, retractor sleeve 500 can be withdrawn from incision HI. Anchor 60 a and anchor extension 230 a are secured to vertebrae V2 using the techniques described herein. For example, a guidewire can be anchored to a desired location on vertebra V2 using lateral fluoroscopy or other image guidance instrumentation, and anchor 60 a and anchor extension 230 a are placed over the guidewire and anchor 60 a secured to vertebra V2. Alternatively, anchor 60 a and anchor extension 230 a could be percutaneously guided through incision H1 and engaged to vertebra V2. As shown in FIG. 25c, anchor 60 b and anchor extension 230 b can be similarly secured to vertebra V1.

[0113] In FIG. 25d, inserter 224 of installation instrument 220 is mounted on anchor extensions 230 a and 230 b. Connecting element or brace 290 is coupled to inserter 224, and is shown in a position adjacent skin S of the patient before percutaneous insertion of connecting element 290. In FIG. 25e, brace 290 is percutaneously inserted and passed through passageways defined by receiving portions on anchors 60 a and 60 b. Brace 290 is then secured to anchors 60 a and 60 b with set screws. In FIG. 25f, inserter 224 and anchor extensions 230 a, 230 b of installation instrument 220 are removed. As also shown in FIG. 25g, the entry location of connecting element 290 forms a puncture wound H2 that is spaced and remote from incision Hi.

[0114] The surgical technique provides for surgical treatment and/or stabilization of at least vertebrae V1 and V2. Surgical procedures are performed in or adjacent vertebrae V1 and V2 through retractor sleeve 500. Anchors 60 a, 60 b are engaged to vertebrae V2 and V1, respectively, through the same incision HI. The adjacent vertebrae V1 and V2 are stabilized by installing brace 290 through puncture wound H2. Thus, a minimally invasive surgical technique is provided the only requires an incision for surgical procedures in or adjacent to the disc space and vertebrae V1 and V2, and a puncture would for stabilization of vertebrae V1 and V2 with a connecting element.

[0115] While the invention has been illustrated and described in detail in the drawings and foregoing description, the same is to be considered as illustrative and not restrictive in character, it being understood that only the preferred embodiment has been shown and described and that all changes and modifications that come within the spirit of the invention are desired to be protected. 

What is claimed is:
 1. A minimally invasive surgical method, comprising: making an incision in a patient; placing a first anchor through the incision; engaging the first anchor to a first bony element; placing a second anchor through the incision; engaging the second anchor to a second bony element; and positioning a connecting element in the patient to a desired position relative to the first anchor and the second anchor through an entry location in the patient remote from the incision.
 2. The method of claim 1, further comprising: placing first and second anchor extensions on respective ones of the first and second anchors; and mounting an inserter on the first and second anchor extensions; and positioning the connecting element through the entry location to the desired position with the inserter.
 3. The method of claim 2, wherein the connecting element is curved, the inserter has a pivot axis, and positioning the connecting element includes swinging the connecting element through an arc in a plane containing the connecting element and perpendicular to the axis of curvature of the connecting element.
 4. The method of claim 3, wherein positioning the connecting element includes passing the connecting element through passageways of the anchors.
 5. The method of claim 4, wherein the pivot axis of the inserter is at a fixed distance from the passageways equal to the radius of curvature of the connecting element.
 6. The method of claim 1, further comprising: using image guided navigation to orient the first and second anchors with respect to the first and second bony elements; and placing the first and second anchors includes placing the first and second anchors percutaneously through the incision.
 7. The method of claim 1, further comprising: using image guided navigation to orient and place guidewires through the incision and into each of the first and second bony elements; placing the first and second anchors includes guiding the first and second anchors over a corresponding one of the guidewires; and removing the guidewires after engaging the first and second anchors to the first and second bony elements.
 8. The method of claim 1, wherein the first and second bony elements are first and second vertebral elements, respectively, and further comprising: inserting through the incision at least one interbody fusion device in an intertransverse space between the first and second vertebral elements.
 9. The method of claim 1, wherein the entry location is a percutaneous puncture.
 10. The method of claim 1, wherein the first and second bony elements are first and second vertebral bodies, respectively, and further comprising removing through the incision intervertebral disc material from a disc space between the first and second vertebral bodies.
 11. The method of claim 1, further comprising: inserting a retractor sleeve through the incision before placing the first anchor and the second anchor; and performing a surgical procedure through the retractor sleeve.
 12. The method of claim 11, wherein the first and second bony elements are first and second vertebral elements, respectively, and further comprising: inserting at least one interbody fusion device through the retractor sleeve and into an intertransverse space between the first and second vertebral elements.
 13. The method of claim 12, further comprising: removing the retractor sleeve before placing the first anchor and the second anchor.
 14. The method of claim 1, wherein each of the first anchor and the second anchor is a multi-axial screw.
 15. The method of claim 1, wherein the connecting element is positioned percutaneously to the desired position.
 16. A minimally invasive surgical method, comprising: accessing at least one of a disc space and an intertransverse space between adjacent vertebrae from a first location on a patient; inserting from the first location at least one device into the at least one disc space and intertransverse space; engaging from the first location first and second anchors to corresponding ones of the adjacent vertebrae; and positioning a connecting element proximate the first and second anchors from a second location on a patient remote from the first location.
 17. The method of claim 16, wherein engaging first and second anchors includes percutaneously inserting the first and second anchors through the first location.
 18. The method of claim 16, wherein positioning the connecting element includes positioning the connecting element percutaneously from the second location.
 19. The method of claim 16, further comprising removing disc material from the disc space before inserting the at least one device.
 20. The method of claim 16, wherein the at least one device is an interbody fusion device inserted into the disc space through a retractor sleeve percutaneously inserted at the first location.
 21. The method of claim 20, further comprising: removing the retractor sleeve before engaging the first and second anchors.
 22. A minimally invasive surgical method, comprising: making an incision in a patient for accessing first and second bony elements; placing through the incision first and second anchors coupled to first and second anchor extensions, respectively; engaging the first and second anchors to the first and second bony elements, respectively; mounting an inserter instrument on the first and second anchor extensions, the inserter instrument having a pivot axis relative to the anchors and further including a connecting element mounted thereon; swinging the inserter instrument relative to the anchors about the pivot axis and thereby moving the connecting element through an arc centered on the pivot axis of the inserter instrument; introducing an end of the connecting element into the patient from a location remote from the incision; and positioning the connecting element proximate to the first and second anchors.
 23. The method of claim 22, wherein placing first and second anchors includes placing the first and second anchors percutaneously through the incision.
 24. The method of claim 23, wherein introducing the end of the connecting element includes introducing the end of the connecting element percutaneously at the location.
 25. The method of claim 22, further comprising: securing the connecting element to the first and second anchors; disconnecting the inserter instrument from the connecting element; and moving the inserter instrument in a reverse direction through the arc and thereby removing the inserter instrument from the patient.
 26. The method of claim 25, further comprising: unmounting the inserter instrument from the first and second anchor extensions; and uncoupling the first and second anchor extensions from the first and second anchors.
 27. The method of claim 22, wherein the connecting element is positioned through receivers in the anchors after introducing the connecting element.
 28. The method of claim 22, further comprising: removing through the incision material from an intertransverse space between the first and second bony elements; introducing through the incision one or more devices into an intertransverse space between the first and second bony elements; engaging first and second anchors to the first and second bony elements after introducing the one or more devices..
 29. The method of claim 28, wherein introducing the one or more devices includes introducing one or more interbody fusion devices via a postero-lateral approach to the intertransverse space between adjacent vertebrae.
 30. A method of placing a connecting element in a patient, comprising: placing first and second anchors in first and second bony elements of the body through an incision in the patient; mounting an installation instrument on the first and second anchors, the installation instrument having the connecting element secured thereto; and moving the installation instrument to position the connecting element into the patient at a location remote from the incision.
 31. The method of claim 30, further comprising moving the connecting from the location to a position more proximate the first and second anchors.
 32. The method of claim 30, further comprising: securing the connecting element to the first and second anchors after moving the connecting element more proximate the first and second anchors.
 33. The method of claim 30, wherein the incision extends generally in the direction of the central axis of the spine for a distance of about 20 millimeters or less.
 34. The method of claim 30, wherein the first and second bony elements are first and second vertebrae, respectively.
 35. The method of claim 30, wherein the first and second bony elements comprise the same bone.
 36. A minimally invasive surgical method, comprising: positioning through a single incision at least a pair of anchors within a body of a patient; providing a connecting element; referencing a position of the connecting element relative to a position of the pair of anchors; and percutaneously inserting the connecting element into a desired subcutaneous position relative to the pair of anchors from a location remote from the incision.
 37. The method of claim 36, further comprising affixing the connecting element to the pair of anchors.
 38. The method of claim 36, further comprising coupling the connecting element with an insertion instrument mountable on the at least a pair of anchors.
 39. The method of claim 38, wherein coupling the connecting element to the insertion instrument further comprises attaching the connecting element in a predetermined fixed orientation with respect to the insertion instrument.
 40. The method of claim 38, wherein coupling the connecting element to the insertion instrument further comprises attaching the insertion instrument to the connecting element along a longitudinal axis of the connecting element.
 41. The method of claim 36, further comprising at least one additional incision for additional surgical procedures.
 42. The method of claim 36, wherein the incision extends generally in the direction of the central axis of the spine for a distance of about 20 millimeters or less.
 43. A minimally invasive surgical method, comprising: making an incision in a patient; placing an anchor through the incision; engaging the first anchor to a bony element; and positioning a connecting element in the patient to a desired position relative to the anchor through an entry location in the patient remote from the incision.
 44. The method of claim 43, further comprising: placing a second anchor through the incision; engaging the second anchor to a second bony element; and positioning the connecting element in the patient includes positioning the connecting element to the desired position relative to the anchor and to the second anchor through the entry location in the patient remote from the incision.
 45. The method of claim 44, further comprising: placing first and second anchor extensions on respective ones of the first and second anchors; mounting an inserter on the first and second anchor extensions; and positioning the connecting element through the entry location to the desired position with the inserter.
 46. The method of claim 45, wherein the connecting element is curved, the inserter has a pivot axis, and positioning the connecting element includes swinging the connecting element through an arc in a plane containing the connecting element and perpendicular to an axis of curvature of the connecting element.
 47. The method of claim 44, wherein positioning the connecting element includes passing the connecting element through passageways of the anchors.
 48. The method of claim 43, further comprising: using image guided navigation to orient the anchor with respect to the bony element; and placing the anchor includes placing the anchor percutaneously through the incision.
 49. The method of claim 43, wherein the connecting element is positioned percutaneously to the desired position. 